HomeMy WebLinkAbout2025-00053819 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003928730
u, 1 U2 3 4 1 U116 u2 U, 1 1_12 u, 1 U2 1 6 U1 1 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00053819 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
DUNDEE AVE EIIn
® ❑ RELATED ®Y 0 N 08 18 2025 10:40 ®AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT l MI N E S W CONGDON AVE COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EouES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 2 FOR DAMAGED AREA(S) mom TOWED U1 Q
NAME(LAST,FIRST,M) Cuellar Calderon. Maria. E. mo / 1 9 9yr 8 Toyota Camry 2016 �00-NONE ti_ 12 `_, ODE TO CRASH ® ❑
�.:l UNDER CARRIAGE 10 :. 2 FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
F 2 SYTM 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 t6•TOP 3 *Distraction Value ALGN •
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;:il s 4 COM VEH 0 0 1 O0
I . FIRST CONTACT 13 7_ , ,__5 *IrYes.See Sidebar U1
Z Carpentersville I L 60110 0 1 0 5SCB637 CA 2025 REAR
TELEPHONE
IL D 4T1 BE32K56U720157 Falcon ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Dominguez Aranda. Darwin 09720368119 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE.ZIP PHONE NUMBER
RESPONDER
2 rg-
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEON. 0 EWES 0 NMV 0 Ncv 0 DV
yr 12 _ C1
o 13-UNDER CARRIAGE 10 1 c. 2 FIRE ❑ 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
D Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:=5 COM•I sVEH See •Sidebar❑ 0
C
CO
F` --- co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) ISEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
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0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 24 1 08!18 l2025 10 40 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 15 99
! ! ❑PM• ❑Construction *
t
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
-a, ARREST NAME Cuellar Calderon. Maria. E. 6-101 350-641 / / ID PM SLMT
o N 1 ❑ ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
30
t 2 El ARREST NAME AM
7 ! r ❑❑PM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
2 3 ❑
350-Farrell. Heather 102 09 !08/2025 09 00 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r•---, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r '� combination): r gmore thanpounds(example:truck or truck/trailer h,",i_E. 1. Has a weight rating 10,000 5i -<
INDICATE NORTH o p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I it
I (example:shuttle or charter bus):orrr3. Is d ned carry 15 or fewer ssen ers and o rated a contract carrier 0
-A- - ; �
designed to passengers operated
- } } } transporting employees in the course of their employment(example:employee � X
rter-
enger
or
L a--- I I 0 4.Is uosed or designated to translly a van type port betweeicle or n 9 and 15rpassengers,a including the driver,
} } for direct compensation(example:large van used for speific purose):or C
CO
O
L L____a..... J ' t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III�� �wa. placarding(example:placards will be displayed on the vehicle). XI
-- —1
CARRIER NAME Z
__ ADDRESS 0
I D
r (/)Not To Scale CITY/STATE/ZIPC)
- MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 0 Not in Comm./Govt. Not in Comm./Other
;____Y___ 4, USDOT NO. ILCC NO. m
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE